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Based on record reviews, observations, and interviews, the Hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by failure to implement physician orders for 1 (#1) of 5 (#1-5) patient records reviewed for implementation of physician orders, of a total sample of 5.
Findings:

Review of the medical record for Patient # 1 revealed she was admitted to the hospital 2/24/17 for further wound care and IV antibiotic treatment following surgery on her right knee for septic arthritis of the knee. Review of physician orders on admission ( 02/24/17) included daily dressing changes. Review of the Treatment Administration Record revealed no documentation of a dressing change February 25, 26, 28,2017 and no documentation of a dressing change March 01 and 05, 2017. Review of nursing notes for February 25, 26, 28, March 01 and March 05 revealed no documentation of a dressing change to Patient #1's surgical wound to her right knee.

In an interview 03/08/17 at 8:25 a.m. Patient #1 reported when she first arrived (at the hospital), on a weekend, that the staff were not changing her wound dressing daily, as they were supposed to. She indicated that after several days she told them they had to do that regularly (daily) , and indicated staff had changed her dressing daily since speaking with them about this.

In an interview 03/08/17 at 12:50 p.m. S3LPN reported she did most daily wound care in the hospital. She reviewed the TAR for Patient #1, and indicated the patient #1's nurses did the dressing change on patient #1's knee. She reviewed the patient's TAR , reporting she had just returned after being out of work, and verified no dressing change was documented on February 25, 26, or 28. She further verified no documentation of a dressing change was noted for March 01 or March 05. She reported that sometimes the nurses would document in the patient's medical record. After a review of the patient's medical record, S3LPN verified she could find no documentation of a dressing change in the nursing notes.

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Based on record review, observation and interview, the hospital failed to ensure the infection control officer assured the system for controlling infections and communicable diseases of patients and personnel was implemented according to hospital policy and acceptable standards of infection control practices as evidenced by:
1) failure to ensure the hospital's policy for isolation precautions was implemented for 2 of 2 (#1, #3) patients reviewed for correct isolation precautions implemented, of a total sample of 5,as evidenced by :
a) a patient (#1) tested for a possible Clostridium difficile infection not placed on Isolation precautions while awaiting the results for a possible Clostridium difficile infection; and
b) having no signage for Enteric Contact Precautions on a patient's (#3) door who was being tested for a possible Clostridium difficile infection.

2) failure to ensure proper hand hygiene was conducted by staff.

Findings:

1) Failure to ensure the hospital's policy for isolation precautions.

Review of the hospital policy titled Clostridium Difficile Guidelines, R.18.43, revealed in part:
1. Contact Precautions- Enteric or Contact Precautions Plus are indicated for patients known to have confirmed Clostridium difficile or patients with diarrhea that are suspected to have CDI. Precautions may be lifted after the patient is without symptoms of diarrhea for > than 72 hours and course of therapy has been completed.

Patient #1
Review of the medical record for Patient#1 revealed she was admitted to the hospital 02/24/17. Review of physician orders revealed an order 2/26/17 to check stool for Clostridium difficile. Further review of the medical record revealed no documentation the patient was placed on isolation precautions required for patients with Clostridium difficile . Review of lab results for Patient #1 revealed an order was submitted, a sample received, and a test resulted on 02/27/17. The test results for Clostridium difficile were negative.

In an interview 03/08/17 at 10:10 a.m., S1Quality/Infection reported patients with orders for Clostridium difficile tests should be put into enteric isolation precautions as soon as it is suspected the patient potentially has Clostridium difficile , or an order (for testing) is given. She indicated patients put on isolation precautions while awaiting a positive test result are not included on her Infection log until a positive result is received. When asked if Patient #1 was put on isolation precautions when a Clostridium difficile test was ordered, she indicated she would have to ask the patient, after a review of the chart revealed no documentation of the patient having been put into isolation. S1Quality/Infection indicated the hospital did not have a process to ensure patients were put on isolation precautions while awaiting the results of Clostridium difficile testing, as required by their policy and procedure.

In an interview 03/08/17 at 2:20 p.m. Patient #1 reported that she had had a test done on her stool because she had diarrhea. Patient #1 verified that she had not been told she was in isolation, or that anything different had been done by staff, such as use of gowns, or not using waterless handgel. Patient #1 indicated that she didn't know what the test was for, and that no one had told her anything about the results of the test, or if the results were back.

Patient #3
Review of Patient #3's Physician's Orders dated 3/6/17 revealed an order to check stool for Clostridium difficile.

Review of Patient #3's laboratory results revealed no stool had been collected for the Clostridium difficile test as of 3/8/17.

Review of Patient #3's nurses notes dated 3/6/17, 3/7/17 and 3/8/17 revealed his only special precaution listed was fall precautions. Patient #3's medical record had no documentation he had been placed on contact isolation precautions. Further review revealed Patient #3 was documented as having diarrhea on 3/6/17.

In an interview on 3/7/17 at 9:00 a.m. with S1Quality/Infection, she said only Patient #R2 was on isolation precautions.

Observation of Patient #3's room on 3/7/17 at 8:10 a.m. and 3/8/17 at 9:30 a.m. revealed no signs on the doorway in the hall indicating he was on isolation precautions.

In an observation on 3/8/17 at 10:05 a.m., S3LPN was at Patient #3's bedside. S3LPN was not wearing a gown or gloves.

In an interview on 3/8/17 at 10:40 a.m., with S1Quality/Infection, she said when a physician ordered a Clostridium difficile culture the patient should have been put on isolation precautions until the cultures came back negative. S1Quality/Infection also verified the physician had not discontinued Patient #3's order to collect a stool specimen for Clostridium difficile.


2) Failure to ensure proper hand hygiene was conducted by staff.

In an observation on 3/7/17 at 12:00 p.m., S2LPN performed a dressing change to Patient #R1's right ankle. S2LPN was observed removing the old dressing, discarding her gloves and donning new gloves. S2LPN then cleaned the wounds to the right ankle, removed her gloves and donned new gloves. S2LPN then applied the clean dressings to the sites on the right ankle, removed her gloves and donned clean gloves. S2LPN then wiped off her scissors and the bedside table, then removed her gloves and donned new gloves. S2LPN then collected the trash in the room and set the bags by the door. S2LPN did not wash or sanitize her hands during the entire observation.

An observation was made of Patient #3's wound care by S3LPN beginning on 3/8/17 at 1:15 p.m. S3LPN donned clean gloves and rolled Patient #3 onto his side and removed a dressing from his sacrum. S3LPN then removed her gloves and donned clean gloves. S3LPN applied a clean dressing to Patient #3's sacrum then removed the dressing to his right heel with the same gloves. S3LPN then changed gloves and removed the dressing from Patient #3's left heel. After changing gloves, S3LPN applied a clean dressing to Patient #3's left heel, changed gloves, and applied a clean dressing to his right heel. S3LPN then was observed using the dirty gloves to move a bedside table. S3LPN then touched the call bell, touched the remote control and moved Patient #3's sandwich closer to him. S3LPN was then observed picking up a bio hazardous bag, removing one glove at a time and throwing them into the bag. She then placed the bag by the door with her bare hands. S3LPN did not wash or sanitize her hands throughout the entire observation.

In an interview on 3/8/17 at 2:15 p.m. with S4DON, she verified the nursing staff should have washed or sanitized their hands between clean and dirty activities and after glove changes.